Faculty Bibliography

Introduction: Infestation with Pediculus species, or common lice, is frequently diagnosed in the emergency department (ED). Because lice ingest human blood, prolonged and heavy infestation can plausibly lead to iron deficiency anemia. Severe anemia attributable to lice infestation has infrequently been reported to date. Our objective in this study was to retrospectively review cases of lice-related anemia at a single public hospital to identify risk factors and associated demographic and clinical features of this disease process. Methods: We screened the medical records for patients presenting to the ED of an urban public hospital between 2016–2024 for the diagnoses of lice infestation and severe anemia (hemoglobin < 7 grams per deciliter (g/dL). Cases were reviewed for clinical and demographic characteristics. Results: A total of 932 patients were diagnosed with pediculosis infestation in the ED during the study period; 332 (35.6%) of those patients had a complete blood count obtained by the treating team. Thirty-seven cases of severe anemia were identified (3.9% of total pediculosis cases, 11.1% of those for whom a complete blood count was obtained); 84% were microcytic, indicating iron deficiency anemia. Twenty-five patients (68%) were undomiciled, and nine patients (24%) were shelter domiciled. Twenty-three patients (62%) had comorbid psychiatric diagnoses, and 21 (51%) had substance use disorders. The median hemoglobin was 4.4 g/dL (range 2.4-6.9 g/dL). Thirty patients (81%) were admitted to a medical floor and seven patients (19%) to an intensive care unit, each with a comorbid primary condition. Conclusion: In this cohort, anemia secondary to lice infestation was seen in patients with unstable housing, substance use disorders, and psychiatric disease. Most patients were hemodynamically stable, consistent with the proposed mechanism of chronic blood loss. The prevalence of this condition may be higher than previously noted among this vulnerable population. Emergency physicians should be aware of this rare but potentially serious disease process.

INTRODUCTION/BACKGROUND:Infestation with Pediculus species, or common lice, is frequently diagnosed in the emergency department (ED). Because lice ingest human blood, prolonged and heavy infestation can plausibly lead to iron deficiency anemia. Severe anemia attributable to lice infestation has infrequently been reported to date. Our objective in this study was to retrospectively review cases of lice-related anemia at a single public hospital to identify risk factors and associated demographic and clinical features of this disease process. METHODS:We screened the medical records for patients presenting to the ED of an urban public hospital between 2016-2024 for the diagnoses of lice infestation and severe anemia (hemoglobin < 7 grams per deciliter (g/dL). Cases were reviewed for clinical and demographic characteristics. RESULTS:A total of 932 patients were diagnosed with pediculosis infestation in the ED during the study period; 332 (35.6%) of those patients had a complete blood count obtained by the treating team. Thirty-seven cases of severe anemia were identified (3.9% of total pediculosis cases, 11.1% of those for whom a complete blood count was obtained); 84% were microcytic, indicating iron deficiency anemia. Twenty-five patients (68%) were undomiciled, and nine patients (24%) were shelter domiciled. Twenty-three patients (62%) had comorbid psychiatric diagnoses, and 21 (51%) had substance use disorders. The median hemoglobin was 4.4 g/dL (range 2.4-6.9 g/dL). Thirty patients (81%) were admitted to a medical floor and seven patients (19%) to an intensive care unit, each with a comorbid primary condition. CONCLUSION/CONCLUSIONS:In this cohort, anemia secondary to lice infestation was seen in patients with unstable housing, substance use disorders, and psychiatric disease. Most patients were hemodynamically stable, consistent with the proposed mechanism of chronic blood loss. The prevalence of this condition may be higher than previously noted among this vulnerable population. Emergency physicians should be aware of this rare but potentially serious disease process.

STUDY OBJECTIVE/OBJECTIVE:This study aimed to determine the level of agreement among pediatric emergency medicine (PEM) physicians in whether various point-of-care ultrasound (POCUS) video clips represent cardiac standstill in children and to highlight the factors that may be associated with the lack of agreement. METHODS:A single, online, cross-sectional, convenience sample survey was administered to PEM attendings and fellows with variable ultrasound experience. PEM attendings with an experience of 25 cardiac POCUS scans or more were the primary subgroup based on ultrasound proficiency set by the American College of Emergency Physicians. The survey contained 11 unique, 6-second video clips of cardiac POCUS performed during pulseless arrest in pediatric patients and asked the respondent if the video clip represented a cardiac standstill. The level of interobserver agreement was determined using the Krippendorff's α (Kα) coefficient across the subgroups. RESULTS:A total of 263 PEM attendings and fellows completed the survey (9.9% response rate). Of the 263 total responses, 110 responses were from the primary subgroup of experienced PEM attendings with at least 25 previously seen cardiac POCUS scans. Across all video clips, PEM attendings with 25 scans or more had an acceptable agreement (Kα=0.740; 95% CI 0.735 to 0.745). The agreement was the highest for video clips wherein the wall motion corresponded to the valve motion. However, the agreement fell to unacceptable levels (Kα=0.304; 95% CI 0.287 to 0.321) across video clips wherein the wall motion occurred without the valve motion. CONCLUSION/CONCLUSIONS:There is an overall acceptable interobserver agreement when interpreting cardiac standstill among PEM attendings with an experience of at least 25 previously reported cardiac POCUS scans. However, factors that may influence the lack of agreement include discordances between the wall and valve motion, suboptimal views, and the lack of a formal reference standard. More specific consensus reference standards of pediatric cardiac standstill may help to improve interobserver agreement moving forward and should include more specific details regarding the wall and valve motion.

INTRODUCTION/BACKGROUND:Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period. METHODS:After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation. RESULTS:82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention. CONCLUSION/CONCLUSIONS:ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

Background and Objectives: Medical response teams deployed by the Emergency Department (ED) may be necessary to provide care for non-hospitalized patients outside of the ED. Knowledge and consistency of the medical response flow may vary by practitioners. The impact of targeted training videos for these medical response teams has not been well studied. The objective of this study is to assess the use of a training video to provide education of the medical response workflow to ED providers in the delivery of medical care to non-hospitalized patients outside of the ED Methods: A training video was developed to address medical response flow, including coverage hours, team assignments, medical equipment accessibility, hospital coverage areas, and building entry points. The video was shown to Emergency Medicine attendings, fellows, residents, and nurse practitioners during academic conferences. A survey using a Likert scale and multiple answer questions was administered prior to showing the video to assess baseline knowledge. The same questions were surveyed upon conclusion of the video. Analysis using independent sample t-test were used to assess group responses in the pre and post training video questions. Mean scores were also stratified by provider groups Results: 64 of the 79 surveyed completed both pre and post training video questions. There were significant increases in mean scores from the groups overall between the pre and post video surveys when participants were asked who would respond to medical requests outside the ED (M=6.9, SD=2.7 vs M=8.6, SD=2.0; t(133)=-3.9, p=<0.001), knowledge of response team coverage area (M=5.8, SD=3.1 vs M=8.6, SD=2.0; t(133)=-6.2, p=<0.001), building entry points (M=5.7, SD=3.0 vs M=8.7, SD=1.8; t(133)=-4.0, p=<0.001), medical equipment accessibility (M=5.5, SD=3.2 vs M=8.9, SD=1.9; t(133)=-6.7, p=<0.001), and coverage hours (M=5.5, SD=3.2 vs M=8.9, SD=1.9; t(133)=-7.3, p=<0.001). The mean score differences were often more significant in resident groups than other provider groups on the same surveyed questions
Conclusion(s): Training video may be used as an education tool for ED providers who response to medical response team requests for non-hospitalized patients outside the ED. Future assessments should be evaluated for knowledge retention and consistency in medical response team flow among providers